BEARD—A Potential Donor Site in Grade 6 and Grade 7 Alopecia: A Case Series

Abstract

Background

Autologous hair transplantation has been the convention in cases of androgenic alopecia. Routinely, the occipital area serves as an ideal donor site. The advent of follicular unit extraction (FUE) has made body and beard hair harvest a possibility. Beard hair, in particular, has been far more sought after than other parts of the body.

Materials and Methods

A case series of 20 patients have been documented wherein cases with Grade 6 and 7 androgenic alopecia have been treated with beard hair as an adjunct donor site. The local anatomy, procedural technicalities and method of harvesting have been emphasized. The pre, intra and postoperative records have been maintained.

Discussion

The advent of FUE paved way for minimal downtime, better cosmesis and less scarring facilitating the possibility of using non-scalp hair in hair restoration, thus increasing the overall donor graft availability. Beard hair has its characteristic differences when compared to the scalp hair. Alongside there exists an array of advantages and disadvantages.

Conclusion

Minimal complications and potential advantages have encouraged the usage of beard graft in the recent past. In hindsight, beard to scalp transplantation is a worthwhile alternative in cases demanding an expanded source of donor hair which demands further literary contribution.

Introduction:

Literary evidence of hair transplant can be traced as early as the 1930’s in the Japanese literature, popularized as Sasagawa [1]. Okuda introduced 2–4 mm punches with the notion of smaller punches yielding superior cosmesis [2]. By 1943, Tamura treated 137 cases of non-androgenic alopecia having diverse aetiologies using techniques similar to modern day hair transplantation [3]. 1960s and 1970s saw the usage of large grafts that eventually gave way to mini-grafts in the 1980s [4] finally terminating into mini-micrografting in the early 1990s [5].

The term follicular unit was first defined by Headington in 1984 [2] and later elaborated by Bernstein and Rassman in 1995. The concept of follicular unit extraction (FUE) was mapped out by the latter in 1997 [6, 7]. The drawbacks of conventional follicular unit transplantation (FUT) namely the linear scar at the donor site among others, justified the advent and popularity of follicular unit extraction (FUE) [3]. Moreover, FUE offered diversity in terms of area of harvesting. [7].

In individuals with Norwood Hamilton Grade 6–7, there exists a paucity in the available donor scalp grafts and the recipient area requiring coverage. In such cases, body hair graft from sites like beard, chest and legs can meet the potential follicle supply [8].

Body hair transplantation has gained immense popularity in the recent past as an appropriate adjunct for patients with limited occipital donor hair. Beard grafts are unique since they are significantly coarser, darker and thicker than any other source. The advent of FUE further facilitates the harvesting of beard hair grafts.

Hirai et al. [9] had described the use of modified 18-gauge hypodermic needles to harvest beard hair by extracting single follicles to the level of the subdermis. The latter were then used to restore the eyebrows of 3 patients. Poswal et al. [10] mentioned the use of beard donor hair as an effective modality for previous strip scars. Beard hair has been successfully used for androgenetic alopecia (AGA) and scar tissues, with a reported survival rate of nearly 80% [11]. Transplanting non-scalp hair using FUE is demanding and technically challenging for the surgeon. Drawing parallels between the hair characteristics at donor and recipient sites is a challenge [8].

This article attempts to present the application of beard graft as a potential hormone resistant donor area in cases of hair restoration in Grade 6 and 7 alopecia.

Materials and Methodology

A documentation of 20 cases wherein beard hair was deemed as the donor site in patients with grade 6 and grade 7 alopecia have been enlisted. The cases were performed spanning from 2016 to 2020 at the Clinique, Navi Mumbai.

Patient selection criteria:

1. ASA Grade I.

2. Male.

3. Norwood and Hamilton Grade 6 and Grade 7 alopecia.

4. Age: 30–60 years.

Preoperative Preparation

Oral antibiotic namely Cefuroxime 500 mg (Tab Ceftum 500 mg BD) and an anti-fibrinolytic agent (Tranexemic Acid 500 mg BD) were prescribed a day before the procedure. Patients were asked to shave a week prior to the surgery. On the day of the procedure, the beard hair was trimmed to 1 mm in length so that the late phase anagen hair could be readily identified. The patients were asked to apply EMLA (Eutetic Mixture of Lidocaine and Prilocaine, PRILOX) cream (Fig. 1) 1 h prior to their arrival at the clinic with the aim to alleviate the pain caused by local anaesthetic injections.

Fig. 1.

Application of EMLA cream 1 h prior to the procedure

Operating Site and Position

For the purpose of facial anatomic comprehension, the donor site can be divided into the moustache and chin region, the cheek region and the submandibular region (Fig. 2a). The cheek beard is of cosmetic significance. The submandibular area is usually regarded ideal for graft harvesting. The donor area was outlined (Fig. 2b). The patient was asked to maintain a supine position with neck extended such that the cervical beard could be readily accessible (Fig. 3). A face mask was placed to cover the eyes and the nose as a shield from the operating light and to prevent the patient from exhaling upon the operating surgeon. For the surgeon, graft harvesting from the central zone comprising of submental and submandibular area required a chair position of 11–12’o clock. For the left and right submandibular zones, 10 and 2’o clock positions deemed suitable.

Fig. 2.

a Anatomic demarcation of the beard area can be grossly into the moustache and chin (1, Red), the cheek beard (2, Yellow) and the submandibular area (3, Blue). (1) and (2) Preserved for aesthetic reasons while (3) becomes the site of harvesting. b Marking the donor area on the patient

Fig. 3.

Patient position with extended neck for beard harvesting

Intra Operatively

Surgical preparation involved painting and draping. Local anaesthesia in the form of ring block was injected around the marked zone using insulin syringes. The anaesthetic solution used contained 10 ml Lignocaine (2%, 1:1,00,000 conc.), 3 ml Bupivacaine and 2 ml of normal saline. Sodium bicarbonate in the ration of 1:10 was added immediately before injecting to minimize the pain during local anaesthesia administration. Tumescent anaesthesia was injected with 5-ml luer-lock syringe and 24-gauge needle with the aim to make the operating surface taut and to assist in vasoconstriction. It comprised of 100 ml saline, 0.5 ml (1:1000 adrenaline), 5 ml lignocaine and 1 ml triamcinolone (Kenacort 20 mg/ml).

A 0.7 mm cole-type titanium punch (Fig. 4) was used at 600–800 rpm. Initially, 8–10 grafts were punched followed by extraction of those to familiarize with the type, length and thickness of the graft. The former helps in predicting the further punching pattern. The dermal thickness of the beard region is far less when compared to the scalp thereby necessitating superficial punch depth. The assistant was asked to stretch the cervical & facial skin on the body and angle of the mandible to provide optimal counter traction. Additionally, this ensures a stable base for unimpeded graft extraction.

Fig. 4.

a 0.7 mm (outer diameter) titanium punch. (Courtesy: Tejco Surgicals). b Extracted beard grafts, spread and counted

The procedure spanned 4–5 h for about 1500–1800 grafts. Beard grafts were usually addressed on day 2 or 3 of the surgery and was used in conjunction with the occipital grafts for implantation. Beard grafts were mainly used to cover the midscalp and the vertex region.

Postoperative medications included Dexamethasone, 8 mg. IV and Tablet Prednisolone 10 mg for a period of 3 days. Locally, tincture iodine application followed by chlorhexidine dressing was done. The beard area discourages a tight dressing, thus a face mask was placed over the dressing to prevent its dislodgement. Dressing was removed after 24 h and topical antibiotics (Clindamycin/Nadifloxacin) and topical steroid (Mometasone) application was advised thrice a day for the following week. The latter prevents the incidence of post-inflammatory hyperpigmentation (PIH) during the healing phase. Local massage with Scar revision cream (CICATRIX) was advised since 2 weeks postoperatively for the duration of 4 months.

The patients are advised to withheld shaving for 10 days post the procedure. Exposure to sunlight or activities like swimming must be avoided in the initial week following graft harvesting.

A follow-up was scheduled after a week and 20 days thereafter. All clinical photographic records are maintained (Figs. 5, 6).

Fig. 5.

(Left to Right) a Preoperative picture (Grade 6 alopecia). b: The recipient site. c The beard acting as the adjunct donor site. d and e Postoperative follow-up after 9 months

Fig. 6.

(Left to Right) a Preoperative frontal view of Grade 6 alopecia patient. b Postoperative 6 months follow up

Discussion

FUE technique involving harvesting of grafts from the genetically unaffected occipital and temporal areas for implantation to region of alopecia on the scalp has been the standard practice [11]. Regardless of the type of the technique used, FUE or FUT, the use of scalp as the donor site has been the norm [8].

The advent of FUE paved way for minimal downtime, better cosmesis and less scarring facilitating the possibility of using non-scalp hair in hair restoration, thus increasing the overall donor graft availability [14, 15].

Patients presenting with extensive androgenic alopecia with inadequate scalp donor graft necessitates the demand for an alternative pool of donor hair. The other sites include beard hair and body hair [16]. The usage of non-scalp donor hair in FUE must be attempted incorporating the following considerations in terms of the hair follicles. Hair follicles renew themselves through a cycle consisting of three distinct phases: (1) anagen, (2) catagen and (3) telogen. Research into a fourth phase, commonly called the exogen phase, is ongoing [13]. Although 85–90% of scalp hair is anagen hair, between 40 and 85% of body hair can be in the telogen phase, and the anagen phase of body hair is much shorter, a few months compared with several years for scalp hair [16, 18]. Consequently, the characteristics of the recipient hair have to be matched to the donor hair, taking into account the hair diameter, colour, waviness typical rate of growth and shaft angle [8]. This necessitates proper mixing of the scalp and body hair grafts at the implantation site.

The Advantages of Beard Hair to Scalp Transplantation are [12]

• Beard hair is usually much thicker than scalp hair which helps in creating more volume in transplanted areas.

• Expanded donor supply to enable restoration of hirsute individuals with extensive baldness and inadequate scalp donor supply.

• Preserving donor hair on the traditional scalp safe zone for more critical areas such as hairline and temporal points.

However, There are Certain Limitations, Such as [12]

• Although coarse thickness of beard hair is beneficial to some patients who need more bulk, the coarse hair can be problematic in some areas where hair is naturally finer like temporal points and hairline. It is better to reserve beard hair as filler in the mid crown and vertex region.

• Achieving profound anaesthesia in the complete beard area is challenging as the region is supplied by multiple sensory nerve endings.

• The average number of hair follicles is usually less than scalp grafts. Less hair per grafts equals less overall coverage.

• Beard hair has lower Anagen/Telogen ratio. This suggests that beard hair follicles spend less time in growth phase while staying in the Telogen or resting phase for a longer period of time.

• Beard graft harvesting can be more challenging. The skin in certain areas of the face is mobile which makes stabilization of the skin for extraction of grafts quite taxing. Frequent change in the angle of the beard hair adds to the complexity.

The orientation, angle and pattern of beard hair varies significantly. Thus, it is imperative to maintain an adequate length of the beard hair that shall assist in gauging the same. This shall minimize the risk of transection of grafts during collection. When taking beard as a supplementary graft for advanced androgenic alopecia, ethnicity ought to be taken into consideration to avoid potential hypopigmentation in the exposed beard area. Beard follicular units in combination with occipital grafts, could considerably enhance the cosmetic result [19].

Certain potential complications of using beard graft involving the harvest area includes itchiness and irritation, swelling, decreased laxity, transient dysesthesia and temporary scabbing and encrustations.

Conclusion

In the recent past, several novel methods and instrumentations have been proposed in the domain of hair transplant. Body hair transplant have broadened the scope of donor hair harvesting. Beard hair is unique owing to its thick and coarse nature. Male patients with advance alopecia necessitating an extensive donor site can have a viable adjunct in the form of beard graft. Beard hair has its intrinsic advantage of being resistant to the effects of testosterone. The anatomic location and its detailed applied knowledge makes this a favourable donor site for maxillofacial surgeons. Beard hair is coarser when compared to body hair of extremities. Minimal complications and potential advantages have encouraged its usage in the recent past. In hindsight, beard to scalp transplantation is a worth while alternative in cases demanding an expanded source of donor hair grafts. In view of existing literary paucity in this domain, evidence-based documentation is the need of the hour.

Funding

None.

Declarations

Conflict of interest

All author(s) declare that they have no conflict of interest.